Impacts of the economic crisis on public health, part II: Paradigms and the right questions

A year ago I delivered a paper[i] on how local public health departments were being denuded by the economic crisis. Their situation has worsened as unemployment climbs, the federal government pursues a bipartisan prop-up of a probably bankrupt and largely corrupt financial sector and prosecutes gratuitous military actions, while state revenues decline, with the budgets of California, Illinois, Michigan, New York and several other states tied in a Gordian Knot.

Most importantly, their is no widespread social awareness that we are entering what Jim Kunstler calls “The Long Emergency[ii],” what I non-poetically describe as a sustainability crisis that manifests itself as fiscal/economic but whose resolution begins with a grasp of underlying ecological realities. Further, signs of nascent political upheaval are everywhere, but I leave this critical dimension to more capable observers to articulate.

As a public good lacking market support public health depends upon state financing to function. If we are entering The Long Emergency, an increase of governmental support for public health –which was meager before the crisis- is improbable because state and municipal services, commitments and other expenditures will continue to contract. For instance, “states have resolved their FY 2010 budget gaps with an approximately 2:1 ratio of spending cuts to tax increases.”[iii]

In the macro-context, our society is at risk to both systemic financial and energy-scarcity induced breakdown[iv] and disruption that will reduce our ability to maintain current levels of social and technological complexity. In a novel the author would at this point use plot, character and literary devices to drive this message into the “feeling structures”[v] of the reader: we can no longer rely on economic growth –which must be separated from economic development- to solve social problems, ensure the health of the public, add new levels of social complexity, and provide political legitimacy and social cohesion. As illogical as it seems to American Dream imaginings, we must consume less and share more if we are to survive the great ecological transition underway.

The principal health policy question we should be asking is, How should we think about the conundrum of mounting threats to the health of the public with declining resources to meet these threats? I take this question up here. In a subsequent essay I will ask, What kinds of public health systems –not all regions have identical needs- are viable in a contracting economy and how do we create them?

To learn how other health policy analysts view the current crisis I did a Google search for “economic crisis+public health.” To my dismay the first match that came up is my year old conference paper. To the extent that the crisis has garnered attention public health professionals cast it as a “weather the storm” condition. Here are some examples from this literature search:

In the fall of 2009 the World Health Organization[vi] released this statement: “It is not yet clear what the current financial crisis will mean for low-income and emerging economies, but many predictions are highly pessimistic.” The WHO policy position is that economic growth needs to restart so as to strengthen public health infrastructure.

In November 2009 the National Coalition of STD Directors reported on a study of the effects the economic crisis is having on sexually transmitted disease (STD) programs and public health infrastructure. “These cuts threaten our national ability to control both STDs and our entire public health infrastructure,” said Dr. William Wong, lead author of the study. The study recommendation is that when growth resumes STD and all public health funding should be increased.

An early 2010 report funded by The Robert Wood Johnson Foundation argues that funding for public health is in jeopardy in all states –states, not the federal government, are the primary funders of public health departments. The report suggests increased funding for public health but does not say how this can occur since the states are in a downward revenue-generating spiral while facing mounting demands on their budgets. This report too presumes a return to economic growth is necessary.

Finally, there is a smattering of “crisis as an opportunity for reform” reports and seminars. For example a year ago I wrote a review[vii] of two papers by prominent scholars that argue the fiscal/economic crash has provided a teaching moment for health professionals to highlight for governmental officials and other policy-makers the far-reaching effects of [economic decline on] the social determinants of health. I corresponded with one of these authors who informed me that he expected a return to economic growth.

These analysts are committed to logical incrementalism, “the science of muddling through”[viii]. But this purposefully short-term approach to policy making is waning because in the long-term our society cannot function –fiscally, politically, economically- as it does today.

Following Kuhn, the above interpretations:

…constitute … normal science… an attempt to force nature into the preformed and relatively inflexible box that the paradigm supplies. No part of the aim of normal science is to call forth new sorts of phenomena; indeed those that will not fit the box are often not seen at all. Nor do scientists normally aim to invent new theories, and they are often intolerant of those invented by others.[ix]

Consistent with the belief in perpetual economic growth, nearly all health policy studies call for more funding. For example, at health conferences almost all presenters end their lectures with, “We’re the richest nation in the world; surely we can muster the will to address the [name your issue] health problem…” When on occasion I have attempted to engage them and explain that we are in fact among the world’s largest a debtor nations and facing a sustainability crisis I have been ignored, patronized, or dismissed as uninformed or insensitive. This is because the cardinal metaphor that the economic pie will continue to expand is the font of suggestions for health policy improvements; take that away and the field is stumped for ideas.

Previously, I have written that the arrival of peak oil signals the end of economic growth. I have claimed that an ultimate or distal “cause” of our economic/fiscal crisis is the ecological Bottleneck of resource depletion (primarily peak oil), ecosystem degradation, pollution, and related eco-systems disturbances that can no longer be fobbed off to the future in the name of “saving jobs” or “stabilizing the financial system.” Many of my colleagues have pointed out that the petroleum era is now entering its dénouement with no scalable alternative energy infrastructure yet in place (although there are many would-be alternatives, wind, solar, shale gas, biofuels, nuclear, tar sands, hydrogen, all face one or all these three hurdles: scalability, environmental sustainability, and net sufficient energy return). As for the fiscal dimension, bankers have always been “greedy” and in need of regulation and oversight. What is different this time is that the financial sector (which is several times larger than it was in 1970) has created unprecedented debt and turned to cannibalizing the “real economy” as the opportunities for real wealth creation evaporate with the arrival of peak oil. Indeed, 2004 and 2005 appear to be the years subprime mortgage corruption exploded in a covarying relationship with the peaking of world oil production.

With medicine and public health –and the economy that supports them- ensconced in an ossified paradigm, what are the ways forward?

We must begin by extricating ourselves from what Mary Douglas[x] –similarly to Kuhn and Foucault[xi]– terms the ruts of “institutional thinking.” Specifically, we must cease epidemiological studies, health policy analysis, risk assessment, and strategic management thinking that assumes a growing economy.

Here I offer a sketch of panarchy, developed from ecological theory by C. S. Holling[xii] and his colleagues. Panarchy’s basic question is, How to account for stability and change –and by implication growth and decline- in natural ecological systems? Its origins are in the study of forest systems and it has been elaborated to include the study of how human socioeconomic activity is made possible by the earth’s ecosystems. This is a reversal of received economic reasoning where the “environment” is defined as passive and under the control of human intelligence and the supply of natural resources is for all practical purposes assumed to be infinite. Panarchy therefore offers an alternative explanation –a rival paradigm- of how human economy and natural ecology interact.

Holling, interviewed by Thomas Homer-Dixon in 2009, remarked:

… over the years my understanding of the adaptive [ecological] cycle has improved, and I’ve also come to better understand how multiple adaptive cycles can be nested together-from small to large-to create a panarchy. I now believe that this theory tells us something quite general about the way complex systems, not just ecological systems, change over time. And collapse is usually part of the story.

“… I think rapidly rising connectivity within global systems-both economic and technological-increases the risk of deep collapse. That’s a collapse that cascades across adaptive cycles -a kind of pancaking implosion of the entire system as higher-level adaptive cycles collapse, which causes progressive collapse at lower levels.”[xiii]

The exploitation phase is one of rapid expansion, when a population finds a fertile niche in which to grow. “Pioneers” and “Opportunists” exploiting natural resources characterize this phase.

The conservation phase is one in which slow accumulation and storage of energy and material is emphasized as when a population reaches carrying capacity and stabilizes for a time. This phase is characterized by “Climax” and “Consolidation.”

Release, or creative destruction,occurs when a previously successful population declines due to resource exhaustion (in our case, peak oil) or changed conditions, such as fire, storm, or pestilence.

Reorganization or renewal can occur rapidly, as when certain members of the population are selected for their ability to survive despite the changed conditions that triggered the release. This requires appropriate types and scale of natural resources.

“… we [can] think of humankind-including all our interactions with each other and with nature and all the flows of materials, energy, and information through our societies and technologies-as one immense social-ecological system. As this grand system we’ve created and live within moves up the growth phase of its adaptive cycle, it’s accumulating potential in the form of people’s skills and economic wealth. It’s also becoming more connected, regulated, and efficient-and ultimately less resilient. And finally, it’s becoming steadily more complex, which means it’s moving further and further from thermodynamic equilibrium. We need ever-larger inputs of high-quality energy to maintain this complexity. In the meantime, internal tectonic stresses-including worsening scarcity of our best source of high-quality energy, conventional oil-are building slowly but steadily.”

How long will the belief in growth as the natural state of the cosmos persist? How long can the growth phase be extended? It is impossible to say; humans appear to be resisting recognition that we are entering a climax phase. At present the US government is attempting to prolong the existence of our financial sector and avoiding –actually not seeing in the Kuhnian sense- the contradiction between a credit and debt based economy and reaching the limits to growth. Bluntly, efforts to “stimulate consumption” are in fact prolonging and worsening the economic crisis and making the release and renewal phase all the more threatening to human populations –because resources needed to build a sustainable system are being allocated to perpetuate one that is unsustainable.

Kuhn notes that paradigms enter into crisis because unsolved anomolies accumulate to the point that they can no longer be avoided or dismissed; ultimately a paradigm must solve reality-based problems or give way to an alternative paradigm.[1] For example, in several Midwestern cities, Detroit, Flint, Youngstown, the literal inability to sustain their geographical footprint and current levels of complexity leaves physical contraction as the only option to pursue. James W. Hughes, dean of the School of Planning and Public Policy at Rutgers University observes about Detroit, an enormous city of 139 square miles with many neighborhoods now having only one or two houses standing per street, “… things that were unthinkable are now becoming thinkable. There is now a realization that past glories are never going to be recaptured.”[xvi]

Currently, the mayor of Detroit wants the population –which has dwindled from 2 million in 1950 to under 1 million today- to be concentrated into adjacent neighborhoods, thus allowing city services and infrastructure to be terminated or reduced in the vacated areas. The future use possibility for these areas appears to be agricultural production.

A cursory reading of the evidence is that Detroit is reflexively –not consciously or by preference- passing through the ecological phases of the panarchy model. The same should apply to Youngstown, Flint and other locations.

Panarchy implies and end to economic growth as a natural phase of the ecological cycle. Many Americans will find this proposition absurd, wrong-headed, offensive, “socialistic” and so on. In regards to the health sciences, public health and medicine in particular, the recognition of panarchy –or a similar explanation that takes full cognizance of the natural ecology we live in- will be as crucial in this 21st century as the discovery of the microbe was in the 20th century.

The next set of questions to ask revolves around how to build stainable health systems in a contracting economy where increases in government funding cannot be expected. This is daunting (where -as they would say in Detroit- the rubber meets the road) and I invite those with views and suggestions, as well as specific real-world problem situations, to share them with me (danbpgh_at_verizon.net).

[1]It is important to note that most accounts of the introduction of “germ theory” into medicine –which is responsible for the establishment of modern public health- present it as linear and straightforward scientific progress. Forgotten is that it was also ideologically congruent with an industrializing society. Overlooked in conventional history is how germ theory: 1) marginalized but did not eliminate ecological/environmental medicine and 2) reinforced the “modern” view that disease should be consider something that “invades” the body to make it “unhealthy”, thus deemphasizing the interaction between the individual and the environment. See: Linda Nash, Inescapable Ecologies: A History of Environment, Disease, and Knowledge. Berkeley: University of California Press. 2006: Pg. 211.

I disagree with the corollary. While the decline of oil production output is concurrent with the decline of the economy, the two are not so intertwined. The economy will rebound. We will learn to use other forms of fuel, transportation and living. The human race is highly adaptable and highly focused on self preservation and survival. There have been a series of recessions for the last 30 years. The culmination of which is now. Once the dust finally settles, we will rebuild. We do not need oil for growth. We do need energy for growth. However, some of the largest sectors are oil and banking. The unfortunate part is that those sectors will not allow growth (especially growth that is contrary to their bottom line) until they have depleted every profitable resource available to them. This means when the oil is gone, we will see Arco and Shell push whatever fuel is profitable and controlled by them.